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Early Mobilisation Benefits and Barriers Audit Results September 2023

Patients benefit psychologically and physiologically from early mobilisation efforts in critical care settings. Evidence-based practice shows reduced incidence of delirium, improved physical function, and shorter lengths of stay. Barriers to implementation include staffing concerns and fear of complications. Overall, 28% of patients were mobilised by noon, with common reasons for exclusion being sedation and ventilation. Further exploration is needed to improve patient mobilisation rates and address reasons for exclusion.

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Early Mobilisation Benefits and Barriers Audit Results September 2023

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  1. Out of bed Out of bed audit audit September 2023 Rachel Wade

  2. Why do we get patients out of bed? Why do we get patients out of bed? Positive psychological benefit to being out of bed/reduced duration/incidence of delirium Neurological stimulus to aid walking and reorientation, improved muscle strength, reduced ICU -AW Increased functional residual capacity aiding secretion clearance Orthostatic stimulus challenge cardiovascular system Chair provides support to the patient. Improved core stability

  3. Evidence based practice Early mobilisation is safe for patients in critical care and has been shown to demonstrate benefits to patients: • Improvements in physical function/mobility • Reduction in LOS • Reduction in ventilation days • Decrease in airway/vascular complications • Reduced/shorted incidents of delirium (McWilliams & Pantelides (2008) NICE (2009), Schweikert et al (2009) Clark et al (2013) McWilliams et al (2015) Nyadhl et al (2017), Zang et al (2019) What is early mobilisation? TEAM trial suggested early rehab is harmful ( adverse events such as altered blood pressure/cardiac arrythmia/desaturation) (Hodgson et al 2015) Adapted to the individual patient rather than one fits all – move towards earlier rehab and what is suitable for the patient (McWilliams @ BACCN conference 2023)

  4. Barriers to early mobilisation -Staff safety concerns - fear of cardiac/respiratory complications Adequate staffing - labour intensive /time required Junior workforce/clinical expertise (Clark et al 2013, McWilliams et al 2016)

  5. Study looking at rehab after critical illness looking to identify good practice and aim to lead to improvements and guidelines

  6. 16 critical care units invited to participate network wide snap 16 critical care units invited to participate network wide snap- -shot audit 5 questions. 5 questions. Data Collection Data Collection Wednesday 2 Wednesday 2nd Sunday 6 Sunday 6th thAugust shot audit ndAugust August August

  7. Number of responses by unit Number of responses by unit Sunday 6thAugust Wednesday 2ndAugust (Total responses 134 – 11 units) (Total responses 101 –10 units) 35 35 30 30 25 25 20 20 15 15 10 10 5 5 0 0 Responses Responses

  8. Time patients get out of bed Time patients get out of bed Sunday 6thAugust Wednesday 2ndAugust TIME PATIENT OUT OF BED TIME PATIENT OUT OF BED 10am, 16, 17% 10am, 22, 16% 11am, 5, 5% 11am, 16, 12% 12pm, 2, 2% 12pm 5 4% not out of bed by 12pm, 91, 68% not out of bed by 12pm, 73,

  9. Options on audit form for patient not able to get out of bed Sedated and ventilated GCS <10 Active GI Bleed/Hb<8 Inotropes, noradrenaline single strength >5mls/hr CVVH via femoral line or neckline if compromised Cardiovascular instability, please specify NIV/ CPAP/HiFlo + >60% O2, NRM (100% O2) Weaning Trial by 12:00 Awaiting review by MDT (e.g., surgical, tissue viability, ortho, pain team) Awaiting CT, MRI, endoscopy, bronchoscopy, ERCP etc. For intubation, extubation or tracheostomy For insertion or removal of lines or catheters CAM +ve Pain not controlled Frequency of chest physiotherapy Attempted transfer but pt medically unstable Admitted to CC after 6am Going to theatre Going on ward bed within 2 hours EOL/withdrawal of life sustaining treatment Patient refused

  10. Sunday 6thAugust Wednesday 2ndAugust Reason not out of bed Number of patients Reason not out of bed Number of patients Sedated and ventilated 28 Sedated and ventilated 30 Other 15 Other 15 GCS <10 10 GCS <10 5 Patient refused 10 Inotropes/norad. single strength >5mls/hr 5 Patient refused 4 Awaiting review by MDT 4 Awaiting review by MDT 3 Weaning trial by 12:00 3 Going on ward bed within 2 hours 3 Intubation/extubation/for tracheostomy 3 Going to theatre 2 EOL/WLST 3 Admitted to CC after 6am 2 Admitted to CC after 6am 1 Pain not controlled 2 Pain not controlled 2 Intubation/extubation/for tracheostomy 2 Going to theatre 1 NIV/CPAP/HIFLO >60% 2 NIV/CPAP/HIFLO >60% 1 Inotropes/norad. single strength >5mls/hr 1 Going on ward bed within 2 hours 1 CVVH line compromised 1 Active GI Bleed/Hb<8 1 Cardiovascular instability 1 Cardiovascular instability 2 Await CT/MRI/Bronch. etc 1 Await CT/MRI/Bronch. etc 1 CAM +ve. 1 CAM +ve. 1 Insertion/removal lines 1

  11. Resources • Wednesday 2ndAugust -1 other unavailable resource • Sunday 6thAugust – 0 reported

  12. Discussion 66 out of 235 ( 28%) patients were out of bed by 12:00 Exclusions – 154 out of 235 ( 65%) Top 3 reasons for exclusion • sedated /ventilated 58 patients (24%) • “Other” 30 patients (12%) • GCS <10 15 patients (6%) Patients refused 14 (5.9%) Variance between weekday/weekend? Weekday - 11 units submitted data. 23% patients out of bed by 12. Weekend – 10 units submitted data. 23% patients out of bed by 12. Limits to audit – did not look at patients getting up after 12 - would be interesting to explore reasons for ‘other’

  13. Are there improvements to be made to increase Are there improvements to be made to increase number of patients getting out of bed? number of patients getting out of bed? Refused? Patient education Other? Staff education Pain control? Further audits? – NoECCN to repeat audit next year - individual units may want to explore further

  14. David Rowe Joanne Iceton Louise Davis Fiona (ward clerk cardio JCUH) Julie Bruce Morag Tiernan Sophie Patterson Andrea Henderson Lisa Skillen Jessica Atkinson Louise McCreadie Louise Lambton Caroline Parker Shelley Coulson Julie Martin Elizabeth Wright Deborah Sykes Liz Place Susan McAlpine Lynette McElheron Nichola Dale

  15. References Clark DE, Lowman JD, Griffin RL, Matthews HM, Reiff DA (2013) Effectiveness of an early mobilization protocol in a trauma and burns intensive care unit: a retrospective cohort study. Physical Therapy 93(2):186-96. Hodgson CL, Stiller K, Needham DM, et al.(2014) Expert consensus and recommendations on safety criteria for active mobilisation of mechanically ventilated critically ill adults. Critical Care, 18:658: 1-9 McWilliams DJ, Pantelides KP (2008) Does Physiotherapy led early mobilisation affect length of stay on ICU? Association of Chartered Physiotherapist in Respiratory Care (40) p5-11 McWilliams D, Weblin J, Atkins G, Bion J, Williams J, Elliott C, Whitehouse T, Snelson C (2015) Enhancing rehabilitation of mechanically ventilated patients in the intensive care unit: A quality improvement project, Journal of Critical Care, vol 30 (1) p13-18 McWilliams, David & Westlake, E.V. & Griffiths, Richard. (2016). weakness on the Intensive care unit - current therapies. British Journal of Intensive Care. 21. 55-59. National Institute for health and Clinical excellence (2009) rehabilitation after Critical Illness, London. Nydahl P, Madlen-Keitziner M, Vater V, Sivarajah S, Howroyd F, McWilliams D, Osterbrink J (2023) Early mobilisation for prevention and treatment of delirium in critically ill patients: Systematic review and meta-analysis Intensive and Critical Care Nursing, (74) Schweickert WD, Pohlman M, Pohlman A, Nigos C, Pawlik A, Esbrook CL, Spears L, Miller M, Franczyk M, Deeprizio D, Schmidt GA, Bowman A, Barr R, McCallister KE, Hall JB, Kress JP (2009) Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial, The Lancet, vol 373 (9678) p1874-1882 Zang K, Chen B, Wang M, Chen D, Hui L, Guo S, Ji T, Shang F ( 2019) The effect of early mobilization in critically ill patients:A meta-analysis, Nursing in Critical Care, vol 25, p 360-367

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